Provider Demographics
NPI:1275701666
Name:LEECH LAKE OUTPATIENT TREATMENT PROGRAM
Entity Type:Organization
Organization Name:LEECH LAKE OUTPATIENT TREATMENT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:A & D PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MELLADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-335-3567
Mailing Address - Street 1:6905 161ST ST. NW
Mailing Address - Street 2:
Mailing Address - City:CASS LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56633-3428
Mailing Address - Country:US
Mailing Address - Phone:218-335-8308
Mailing Address - Fax:218-335-8307
Practice Address - Street 1:6095 161ST AVE NW
Practice Address - Street 2:
Practice Address - City:CASS LAKE
Practice Address - State:MN
Practice Address - Zip Code:56633-3428
Practice Address - Country:US
Practice Address - Phone:218-335-8308
Practice Address - Fax:218-335-8307
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEECH LAKE BAND OF OJIBWE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-19
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty